CONSENT FOR HEALTH COACHING

 

Coaching is intended to simplify, motivate, and prompt behavior change.

Coaching is not a substitute for medical treatment by a licensed healthcare provider.

The information offered is not meant to be construed as medical advice or to be diagnostic or therapeutic.

 

It is critical that you read and understand this document thoroughly.

 

 

 

This Health and Wellness Coaching Services Agreement (“Agreement”) is made by and between Proactive Health Solutions, LLC (“Coach”) and ______________________ (“Client,” “You,” or “Your”) (individually a “Party,” and together the “Parties”) is effective as of the date last signed below.

The Parties agree as follows:

1. Health and Wellness Coaching Services. The Coach will provide You with health and wellness coaching services that will include: video, email, and phone (“Services”).

2. Services will adhere to the following:

• Scheduling. Each coaching session will be scheduled through email for an agreed upon date and time, convenient for both Parties.

• Duration. Each session will last 15 minutes.

• Coaching Session Expectations. You are expected to engage professionally and respectfully during each Session with the Coach. Failure to provide respectful and professional behavior at all times in each Session may be grounds for termination. Termination is made at the Coach’s discretion and may include termination from the Session or from the remainder of this Agreement.

• Weekly Engagement. The Coach will engage with you as agreed upon by both parties.

• Session Cancellation by the Coach. The Coach reserves the right to cancel or reschedule a coaching session, for any reason. You will be notified in advance of the reschedule date for the cancelled session. You will not be charged for a session being rescheduled by the Coach.

• Rescheduling by You. If You need to reschedule a coaching session, You must notify the Coach 48 hours in advance of your next session. The Coach may charge You with a cancellation fee, if You fail to provide the required advance notice.

• Missed or Late to Session. If You are later than 5 minutes to Your session or miss Your session without requesting a timely reschedule, You will forfeit that session and will not be allowed to reschedule. You may be charged a cancellation fee.

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3. Payment & Cost. The total cost of Your Services is $25. You will pay for Your Services using ___________. Failure to provide timely installment payments may lead a $25 late fee on top of Your current balance due. Failure to provide prompt payment in full will delay the start of any subsequent Sessions.

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The Coach does not accept insurance or negotiate with insurers, and the Services are likely not reimbursed by any insurer. You are financially responsible for Your Services and agree to pay the charges incurred.

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4. Term & Termination.

• Term. Your Services will start on ____________ and will end on ______________ (“Term”). If Your Sessions have not been completed before the end of the Term, and You have not requested to reschedule, You will forfeit any remaining Sessions.

• Termination. Both Parties may terminate this Agreement at any time, upon written notice via email to the other Party.

  1. Termination by the Coach. If the Coach terminates this Agreement, You will be provided a refund, pro-rated for Your remaining Sessions. If the Coach terminates this Agreement, due to Your failure to adhere to Section 2.c., above, You will forfeit any refund.

  2. Termination by You. If You terminate this Agreement prior to completion of your Sessions, You will receive a pro-rated refund, less ________.

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5. Disclaimers and Disclosures.

1. No Guarantee. You recognize the Coach cannot guarantee results or any specific outcomes from the

   Services. You are solely responsible for any action taken based on Your interpretation of any information presented or engagement with the Services and the Coach.

2. Educational Purposes, Only. You understand and acknowledge the Services are educational and informational in nature and are provided only as general information to You. The Services are not meant to establish a patient-provider relationship, establish a standard of care, or offer medical, dietary, or therapeutic care, advice, opinion, diagnosis, or treatment. Even if the Coach is a licensed medical provider, the Coach is not functioning in the role of a licensed medical provider while providing the Services, but rather using their training to inform and educate You. The Services are not intended to replace independent professional or medical judgment. The Services are not intended to solicit patients; and should not be relied upon as medical, psychological, or other professional advice of any kind or nature whatsoever. The information provided through the Services should not be used for diagnosing or treating any mental or physical health problem or disease. The information contained in the Services is not comprehensive and does not include all the potential information regarding the subject matter but is merely intended to serve as one resource for general and educational purposes. The Coach is not replacing care currently provided to You by other licensed providers, such as Your current primary care physician. You are responsible for Your own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. You should maintain a relationship with a licensed provider who is available to provide emergent and urgent care to You.

3. Client Responsibility for Self-Care. You understand any inner-directed work or reflection can bring up distressing feelings, images, thoughts, and behaviors. You agree to seek medical assistance or psychotherapy or any other appropriate physical or mental treatment from a practitioner duly licensed in Your State of residence (such as a licensed medical doctor or licensed psychologist) if You find these distressing aspects create a danger for Yourself or for others.

4. Client Limitations. You are responsible to consult with Your physician or a licensed health care provider before starting the Services. By starting the Services, You affirm You are in good physical condition and do not suffer from any mental or physical disability which would prevent or limit Your participation in the Services. You will not start the Services if Your licensed health care provider advises against it.

5. Client Participation. The Parties will work together as a team during Your Sessions to help You reach Your goals. The Coach will help You develop and refine Your goals into actionable and attainable steps, while supporting You throughout Your journey. This requires You to be an active participant for best outcomes.

6. You are responsible to disclose to the Coach any relevant information needed to receive Services safely and efficiently, which may include medication, care, treatment, diagnoses, and assessments from Your licensed medical provider(s).

7. You agree to seek medical assistance for any appropriate physical or mental treatment from a practitioner duly licensed in Your State or residence, if You find You require additional services beyond the scope of this Agreement. The Coach may suggest seeking additional services from a practitioner duly licensed in Your State or residence, if the Coach feels services beyond the scope of this Agreement are needed.

8. Assumption of Risk; Indemnity. You knowingly, voluntarily, and intelligently decide to receive the Services, and You knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of Your assumption of these risks, You agree to release, hold harmless, indemnify, and defend the Coach and their agents from and against any and all claims which You (or Your representatives) may have for any loss, damage, or injury arising out of or in connection with use of the Services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services.

9. Social Media. The Coach will engage in social media practices which protect Your Health Information. Social media includes, but is not limited to: Facebook, Twitter, Instagram, YouTube, Snapchat, blogs, and the Coach’s webpage. Health Information includes, but is not limited to: the results of, or participation in, wellness and lifestyle coaching sessions, health assessments, questionnaires, general wellness and lifestyle education or services; medical history; or information protected under the Health Insurance Portability and Accountability Act of 1996, Public Law 104- 91, as amended, and related HIPAA regulations (45 CFR. Parts 160-164).

   The Coach will receive written permission and release from You prior to recording or posting any testimonials, photos, videos, recordings, or comments online in social media or on the Coach’s website. All Client permissions and releases will be stored and retained for the minimum time, as required by law.

10. Services Provided via Electronic Communications. Sessions provided through an electronic delivery will include electronic communication (including two-way audio-visual communication), as defined by applicable law. There may be limitations to image quality or other electronic problems that are beyond the control of the Coach. Despite reasonable security measures, online communications can be forwarded, intercepted, or even changed or falsified without either Party’s knowledge.

 

6. Confidentiality. You have the right to confidentiality and privacy by the Coach.

• Confidentiality, Generally. The Coach will keep Your Health Information private and will not disclose Your Health Information unless You have provided written authorization, or as required by law or regulation. The Coach will not permit unauthorized access to Your Health Information. Access to Your Health Information by the Coach will be limited to the minimum necessary required for business purposes. Your Health Information will be safely stored, safeguarded, and disposed of in accordance with the Coach’s internal policies. The Coach is not responsible for unauthorized access of Your Health Information if You voluntarily made Your Health Information available for viewing by third parties online (for example on social media).

• Authorization for Release of Health Information and Required Notice. You have received the Coach’s Authorization for Release of Health Information and Required Notice. You acknowledge this must be signed and returned to the Coach prior to starting the Services.

• Business Confidentiality. The Coach’s Services, Program, original materials, business information, and materials used by the Coach with permission from the original author or owner, (collectively referred to as “Materials”) provided to You are for Your individual use only and are a single-user license. Materials are copyrighted and shall remain the sole property of the Coach or the original author or owner. You are not authorized to use any Materials for Your business purposes. You may not sell or distribute Materials. You agree (1) to not infringe on any copyright, patent, trademark, trade secret, or other intellectual property rights, (2) that the Materials are confidential and proprietary, and belong solely and exclusively to the Coach or the original author or owner, and (3) not to disclose the Materials to any person or use it in any manner other than in discussion with the Coach. Further, any violation of this Section is grounds for the Coach’s request of injunctive relief to prohibit any such violations.

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7. General Provisions.

1. Assignment. Neither Party may assign this Agreement without prior written consent of the other.

2. Counterparts. This Agreement may be executed in one or more counterparts, each of which will be deemed an original but all of which together will constitute one and the same instrument. Facsimile, pdf, or electronic signatures will for all purposes have the same force and effect as an original signature on this Agreement.

3. Entire Agreement & Amendment. This Agreement constitutes the entire agreement between the Parties and supersedes all prior agreements, communications, and writings, whether written or oral, between the Parties. The terms and conditions of this Agreement may only be amended by mutual written agreement of the Parties. No other modification, amendment or addition to this Agreement will be valid or enforceable unless in writing and signed by the Parties.

4. Governing Law. Governing Law and Jurisdiction. The construction, validity and performance of this Agreement shall be governed by, and construed in accordance with, the laws of the State of Ohio; and the Parties expressly waive its choice of law rules. The Parties agree that venue and jurisdiction for any litigation arising out of, related to, or regarding the validity of, this Agreement shall be in the Common Pleas Court located in the County of Washington, State of Ohio.

5. Headings. The headings in this Agreement are for convenience of reference only, and under no circumstances should they be construed as being a substantive part of this Agreement nor will they limit or otherwise affect the meaning thereof.

6. Interpretation and Severability. If any provision of this Agreement is held invalid or unenforceable the remaining provisions and paragraphs will continue in full force and effect and will be binding on the Parties.

7. Waiver. The waiver by either Party of a breach or violation of any provision in this Agreement will not operate or be construed as a waiver of any subsequent breach or default of a similar nature, or as a waiver of any such provisions, rights, or privileges. Failure to insist upon full performance of the obligation or failure to exercise rights under this Agreement will not constitute a waiver as to future defaults or exercise of rights.

8. Arbitration: Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this Agreement to arbitrate, shall be determined by, and pursuant to the rules of, the American Arbitration Association ("AAA") in the County of Washington, in the state of Ohio, with each party being responsible for their own expenses, before one (1) arbitrator. The arbitration shall be administered by the American Arbitration Association ("AAA") Rules of Procedure for Arbitration, in Washington County, in the State of Ohio. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either You or Us from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. You agree to submit any claims arising out of this Agreement to binding arbitration, and this dispute resolution provision constitutes a waiver of Your right to a jury trial. HOWEVER, prior to the Parties initiating Arbitration the Parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in Washington County, in the state of Ohio. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution.

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The Client hereby agree to the following: 

 

1. I certify that I have not been advised by a qualified medical professional to avoid or limit certain lifestyle changes. In addition, I am unaware of any health-related reasons for which would preclude my participation in strenuous physical exercise. I assume the risks involved in my lifestyle changes that may test my physical and mental limits & may carry with it the potential for death or serious injury.  Risks may include but are not limited to, adverse consequences caused by the environment, equipment, actions of other people and lack of hydration or nutrition.

2. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

3. I recognize that an examination by a physician should be obtained prior to involvement in any exercise program. If I have chosen not to obtain a physician’s permission prior to beginning exercising or other form of lifestyle change, I hereby agree that I am doing so at my own risk, understanding the potential for adverse consequences.

4. In a medical emergency, I will call 911.

5. For medical advice, I will contact an appropriate healthcare provider.

6. Improving one’s health is NOT an exact science, and I acknowledge that no guarantees have been made as to the results of services.

7. I have been advised by Proactive Health Solutions to consult the appropriate healthcare provider before taking on any life changes. I will discuss all recommendations and services rendered with the appropriately licensed healthcare provider. If I believe that is not necessary, then I will carefully evaluate and take responsibility for all the medical risks of participation in any suggestions or instructions discussed. 

8. I assume full responsibility for the actions I take to improve my health.

9. I understand at no point will there be a physician-client relationship between Proactive Health Solutions, LLC, Darren Swartz, or myself.   

10. I am aware that Darren Swartz is a certified ACE Health Coach and NOT a licensed or practicing M.D., D.O., chiropractor, nurse, dietitian, physical therapist or any other type of licensed practitioner. I know I can freely seek or continue such services at any time from a licensed practitioner.  

11. Health coaching does NOT include: performing physical exams, blood draws, or medical procedures. Also, a coach does NOT provide medical diagnoses, prescribe medical treatments, nor recommend discontinuance of these treatments. Therefore, information should not be construed directly or indirectly as dispensing medical advice for the cure or mitigation of any disease or condition.

12. I will allow Proactive Health Solutions, and its employees to use email/Zoom/Wix Chat/etc. to send me health information that may include personal health information (PHI). You will not be expected to share PHI, nor will your PHI be kept by Proactive Health Solutions, LLC. 

13. I am aware that I am fully in charge of my personal health information and my lifestyle choices. 

14. I will take full responsibility for my records, which includes both physical and electronic copies.

15. I understand that Proactive Health Solutions will not keep a copy of my records with the exception of this consent.  

16. I understand that Uptodate, or another resource, may be used to help me understand my health so that I can better communicate with my physician.

17. I fully understand a health coach’s scope of service:      

    • Apply effective communication skills, such as the use of open-ended questions, affirmations, reflective listening, and summarizing to help a client or patient increase motivation and ownership of making a change           

    • Help clients and patients develop achievable and measurable goals to monitor success and motivate ongoing behavior change

    • Help clients and patients develop and exploit strengths to support successful behavior change

18. I understand the following actions, among others, are outside defined scope of practice for health coaches:

    • Counseling or therapy

    • Nutrition prescription and meal planning

    • Exercise prescription

    • Diagnosis of medical or mental health ailments

    • Recommendation or sale of supplementation

18. I have completed the PAR-Questionnaire.

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Your personal information will not be shared with your employer.

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I have had the opportunity to ask questions and freely agree to the terms as expressed. (See chat box below)